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Primary Carcinoma of the Ureter
PRIMARY CARCINOMA OF THE URETER JAMES C. SARGENT
AND
CHAS. R. MARQUARDT
Milwaukee
In 1922, Aschner (1) reported 47 cases of primary epithelial tumors of the ureter; of these, only four were squamous cell carcinoma. Rousselot and Lamon (2), in January 1930, collected 48 cases of primary carcinoma of the ureter, to which they added a case of their own. Renner (3) in April 1931, in reviewing the literature, believed two of the cases Rousselot and Lamon reported were erroneously included. He was only able to collect 46 cases, to which he added a case of his own and one of Player (4). This brought the total to 48 cases. In the series reported by Rousselot and Lamon, the diagnosis was made twenty times at autopsy, sixteen times at operation, and sixteen times clinically. To this we wish to add a case of our own, bringing the total number of cases to 49. Case report. J. D. 54, white female, single. The patient was first seen November 16, 1932. She always had been in good health and never had had any serious illnesses or operations. She passed her menopause without incident four years ago. She was in excellent health and actively occupied. She weighed 160 pounds, which was her average good weight. One year ago, in the course of a general examination, some red and white blood cells were found in her urine. During the past two months the patient had experienced a discomfort in her right side, front and laterally. She attributed this to gas and felt relieved after alkaline medication. The past three weeks she noticed her urine was heavily colored and, three days previous, had a marked total hematuria. There were no other genito-urinary or general symptoms. Physical examination revealed a well developed, well nourished female, not acutely ill. Examination was negative, except for a palpable right kidney on deep inspiration. Cystoscopy, November 16, 1932. A no. 24 F. cystoscope passed with 625
626
JAMES C. SARGENT AND CHAS. R. MARQUARDT
ease, releasing a faintly hazy urine which showed a moderate number of red cells, and an occasional white cell and colon bacillus. The bladder appeared normal, except that in back of the left ureteral orifice was a small villous tumor delicate in structure, the size of a pea, and arising from a normal mucous membrane. Clear urine spouted from the left
FrG. 1 A, benign papilloma; B, infiltrating carcinoma
side. On the right side, blood rolled continuously from the orifice. A no. 6 F. catheter met obstruction half-way up the right side. It did not drain and frequently clotted with blood. A plain film showed the catheter advanced to the lower part of the sacro iliac joint. The kidney shadow on the right side appeared enlarged. There was no shadow suggestive of a stone. A pyelogram was attempted, but when 2 cc. was injected, she complained of intense pain
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~~~
PRIMARY CARCINOMA OF URETER
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627
in the right abdomen, radiating into the bladder. No solution was found in the kidney, but some regurgitated about the catheter into the bladder. A second forceful injection was made upon partially withdrawing the catheter, but again no solution was found in the kidney or upper ureter. Evidently, the ureter was entirely blocked.
Fm. 2
A diagnosis of primary carcinoma of the ureter and metastatic papilloma of the bladder was made. November 23, 1932, under ethylene anesthesia, the right kidney was cut down upon and found to be an advanced hydronephrosis with intra and extra pelvic dilatation (fig. 1). The upper inch or so of the ureter was widely dilated down to a hard, infiltrated mass the size of a walnut, involving the ureter and perureteral fat. This was intimately attached to the surrounding tissues
628
JAMES C. SARGENT AND CHAS. R. MARQUARDT
at about the point of the obtuse angle to the right of the branching off of the common iliac artery from the aorta. In fact, only with difficulty was the mass separated from the great vessels. An enlarged gland was found lying along the right common iliac artery which was enlarged to the size of an almond, but its intimate
Fm. 3
attachment made removal hazardous. Another gland, the size of a walnut, was attached to the angle of the aorta and right renal artery. The entire kidney and ureter down to a point within an inch below the infiltrated area was removed. The wound was closed with a rolled rubber drain. The patient had an uneventful convalescence and left the hospital December 10, 1932. Dr. John Grill, pathologist at St. Joseph's Hospital, reported the following:
PRIMARY CARCINOMA OF URETER
629
"Gross description (fig. 1). There is a marked distension of the renal pelvis, producing an enormous atrophy of the kidney parenchyma proper. The distended pelvis produces several hollow spaces which are separated by thick bridges of renal tissue. In the periphery of the kidney, the remaining renal tissue is, on the average, about 3 mm. thick. "In the distal portion of the pelvis, close to its junction with the ureter, there is a small, cauliflower-like tumor, the size of a cherry stone (benign papilloma). This tumor protrudes into the lumen and rests with a broad base upon the pelvis mucosa. About 1 cm. distal from this, the wall of the ureter appears markedly thickened by a firm, grayish-white tumor tissue extending about 4 cm. in length. In this area, the lumen of the ureter cannot be found, and the entire ureteral wall is diffusely infiltrated by tumor tissue which extends into the fatty tissue surrounding the ureter." "Microscopic examination (figs. 2 and 3). Sections were taken from the wall of the ureter infiltrated by tumor tissue, and they showed the tumor to consist of large nests and strands made up of squamous epithelial cells diffusely infiltrating and destroying the wall of the ureter. "There were areas found within the tumor containing foci of leukocytes and necrotic areas. "The tumor does not form cornification." On January 9, 1933, the patient had the papilloma in her bladder fulgurated. Subsequently, she has had no complaint and her general health is good. DISCUSSION
The diagnosis of primary malignancy of the ureter is extremely difficult, as the disease is readily confused with tumor of the kidney, hydronephrosis, stone, or tuberculosis. Ureterograms are most helpful but, as in our case, they are difficult to obtain. The usual symptoms are pain and hematuria. Tumor is often felt. Cystoscopically, the diagnosis can be confirmed by seeing the tumor project from a ureteral orifice, visible ureteral bleeding that is profuse, bladder transplants, or the inability to catheterize the affected side. In our case, there was no apparent urinary drainage from the affected side.
307 Wells Building, 324 East Wisconsin Avenue, Milwaukee, Wisc.
630
JAMES C. SARGENT AND CHAS. R. MARQUARDT
REFERENCES (1) AscHNER, P. W.: Primary tumors of the ureter. Surg., Gynecol. and Obstet., 1922, xxxv, 749-58. (2) RoussELOT, L. M., AND LAMON, J. D.: Primary carcinoma of the ureter. Surg., Gynecol. and Obstet., January, 1930, pp.12-28. (3) RENNER, M. J.: Primary malignant tumors of the ureter. Surg., Gynecol. and Obstet., April, 1931, lii, 793-803. (4) PLAYER, L. P.: Primary ureteral carcinoma with case report and a review of the literature. Urol. and Cutan. Rev., 1928, xxxii, 438-444.
AND
CHAS. R. MARQUARDT
Milwaukee
In 1922, Aschner (1) reported 47 cases of primary epithelial tumors of the ureter; of these, only four were squamous cell carcinoma. Rousselot and Lamon (2), in January 1930, collected 48 cases of primary carcinoma of the ureter, to which they added a case of their own. Renner (3) in April 1931, in reviewing the literature, believed two of the cases Rousselot and Lamon reported were erroneously included. He was only able to collect 46 cases, to which he added a case of his own and one of Player (4). This brought the total to 48 cases. In the series reported by Rousselot and Lamon, the diagnosis was made twenty times at autopsy, sixteen times at operation, and sixteen times clinically. To this we wish to add a case of our own, bringing the total number of cases to 49. Case report. J. D. 54, white female, single. The patient was first seen November 16, 1932. She always had been in good health and never had had any serious illnesses or operations. She passed her menopause without incident four years ago. She was in excellent health and actively occupied. She weighed 160 pounds, which was her average good weight. One year ago, in the course of a general examination, some red and white blood cells were found in her urine. During the past two months the patient had experienced a discomfort in her right side, front and laterally. She attributed this to gas and felt relieved after alkaline medication. The past three weeks she noticed her urine was heavily colored and, three days previous, had a marked total hematuria. There were no other genito-urinary or general symptoms. Physical examination revealed a well developed, well nourished female, not acutely ill. Examination was negative, except for a palpable right kidney on deep inspiration. Cystoscopy, November 16, 1932. A no. 24 F. cystoscope passed with 625
626
JAMES C. SARGENT AND CHAS. R. MARQUARDT
ease, releasing a faintly hazy urine which showed a moderate number of red cells, and an occasional white cell and colon bacillus. The bladder appeared normal, except that in back of the left ureteral orifice was a small villous tumor delicate in structure, the size of a pea, and arising from a normal mucous membrane. Clear urine spouted from the left
FrG. 1 A, benign papilloma; B, infiltrating carcinoma
side. On the right side, blood rolled continuously from the orifice. A no. 6 F. catheter met obstruction half-way up the right side. It did not drain and frequently clotted with blood. A plain film showed the catheter advanced to the lower part of the sacro iliac joint. The kidney shadow on the right side appeared enlarged. There was no shadow suggestive of a stone. A pyelogram was attempted, but when 2 cc. was injected, she complained of intense pain
, -
-------------'-· -·--·~--"
~~~
PRIMARY CARCINOMA OF URETER
,,
----~-----~-------------- -
627
in the right abdomen, radiating into the bladder. No solution was found in the kidney, but some regurgitated about the catheter into the bladder. A second forceful injection was made upon partially withdrawing the catheter, but again no solution was found in the kidney or upper ureter. Evidently, the ureter was entirely blocked.
Fm. 2
A diagnosis of primary carcinoma of the ureter and metastatic papilloma of the bladder was made. November 23, 1932, under ethylene anesthesia, the right kidney was cut down upon and found to be an advanced hydronephrosis with intra and extra pelvic dilatation (fig. 1). The upper inch or so of the ureter was widely dilated down to a hard, infiltrated mass the size of a walnut, involving the ureter and perureteral fat. This was intimately attached to the surrounding tissues
628
JAMES C. SARGENT AND CHAS. R. MARQUARDT
at about the point of the obtuse angle to the right of the branching off of the common iliac artery from the aorta. In fact, only with difficulty was the mass separated from the great vessels. An enlarged gland was found lying along the right common iliac artery which was enlarged to the size of an almond, but its intimate
Fm. 3
attachment made removal hazardous. Another gland, the size of a walnut, was attached to the angle of the aorta and right renal artery. The entire kidney and ureter down to a point within an inch below the infiltrated area was removed. The wound was closed with a rolled rubber drain. The patient had an uneventful convalescence and left the hospital December 10, 1932. Dr. John Grill, pathologist at St. Joseph's Hospital, reported the following:
PRIMARY CARCINOMA OF URETER
629
"Gross description (fig. 1). There is a marked distension of the renal pelvis, producing an enormous atrophy of the kidney parenchyma proper. The distended pelvis produces several hollow spaces which are separated by thick bridges of renal tissue. In the periphery of the kidney, the remaining renal tissue is, on the average, about 3 mm. thick. "In the distal portion of the pelvis, close to its junction with the ureter, there is a small, cauliflower-like tumor, the size of a cherry stone (benign papilloma). This tumor protrudes into the lumen and rests with a broad base upon the pelvis mucosa. About 1 cm. distal from this, the wall of the ureter appears markedly thickened by a firm, grayish-white tumor tissue extending about 4 cm. in length. In this area, the lumen of the ureter cannot be found, and the entire ureteral wall is diffusely infiltrated by tumor tissue which extends into the fatty tissue surrounding the ureter." "Microscopic examination (figs. 2 and 3). Sections were taken from the wall of the ureter infiltrated by tumor tissue, and they showed the tumor to consist of large nests and strands made up of squamous epithelial cells diffusely infiltrating and destroying the wall of the ureter. "There were areas found within the tumor containing foci of leukocytes and necrotic areas. "The tumor does not form cornification." On January 9, 1933, the patient had the papilloma in her bladder fulgurated. Subsequently, she has had no complaint and her general health is good. DISCUSSION
The diagnosis of primary malignancy of the ureter is extremely difficult, as the disease is readily confused with tumor of the kidney, hydronephrosis, stone, or tuberculosis. Ureterograms are most helpful but, as in our case, they are difficult to obtain. The usual symptoms are pain and hematuria. Tumor is often felt. Cystoscopically, the diagnosis can be confirmed by seeing the tumor project from a ureteral orifice, visible ureteral bleeding that is profuse, bladder transplants, or the inability to catheterize the affected side. In our case, there was no apparent urinary drainage from the affected side.
307 Wells Building, 324 East Wisconsin Avenue, Milwaukee, Wisc.
630
JAMES C. SARGENT AND CHAS. R. MARQUARDT
REFERENCES (1) AscHNER, P. W.: Primary tumors of the ureter. Surg., Gynecol. and Obstet., 1922, xxxv, 749-58. (2) RoussELOT, L. M., AND LAMON, J. D.: Primary carcinoma of the ureter. Surg., Gynecol. and Obstet., January, 1930, pp.12-28. (3) RENNER, M. J.: Primary malignant tumors of the ureter. Surg., Gynecol. and Obstet., April, 1931, lii, 793-803. (4) PLAYER, L. P.: Primary ureteral carcinoma with case report and a review of the literature. Urol. and Cutan. Rev., 1928, xxxii, 438-444.